A
mountain blizzard rages outside the windows, classes are cancelled at the
University… being socked in for the day, one gets philosophical.

So I
meander over to a philosophy blog where they argue to the point of making reality,
which feels so real, puzzling.

What
was puzzling to me was news coming out of California that a “Nurse” refused to
administer cardiopulmonary resuscitation (CPR) on an 87 year old resident. Upon witnessing a collapsed resident gasping
for breath, the nurse called 911. The transcript
of the 911 call was harrowing. Over
the 7-minute call the dispatcher begged the nurse to administer CPR to save the
woman’s life. The nurse wouldn’t,
instead saying that the independent living facility’s policy prohibited her
from administering CPR. The dispatcher
appealed to the nurse’s humanity. She
asked if there were anyone around who could save the woman. The nurse, even though qualified herself,
said that she would not ask others because they wouldn’t know how. Ms. Larraine Bayless was pronounced dead at
the hospital.

My
philosophical readings this morning had me asking my own puzzling question:
“What is THE truth”; which is in contrast to asking the question “what is
truth”. A blogger named Michael
Lynch was citing other philosophers saying that they get stuck trying to
answer questions that only lead to the frustration of further quarrelsome
questions. He thinks philosophy gets
stuck because philosophers are out looking for THE truth (my interpretation); a
single truth that can be surmised from reducing some explanation to its core…
kind of the way science approaches problems.

For
the nurse in California, the moral question of saving Ms. Bayless’ life got
reduced down to the company’s policies that seemed to be aimed at reducing
liability than acting to save lives. For
her, it was THE truth.

For
Lynch, a single philosophical version of THE truth falls short. The truths of science are truthful because
they correspond to the physical world.
But the truths of mathematics or politics conform to different
realities; Morality, with yet another truth.

In
California, within Brooksdale Senior Living’s facility, a single version of THE
truth failed. Ms. Bayless died, the
company is under scrutiny and the target of public anger, and the rest of us
are puzzled.

This
has happened before in other places, including
hospitals. I remember when I was
earning my Lifeguard certification through the Red Cross. I was taught that the second anyone started a
rescue, throwing a flotation device or going into the water or beginning CPR,
they are personally responsible (liable) for the victim’s outcome. Even at my young age I was aware of the
paradox of the two realities…the treat to the victim vs. the threat to me.

Our
employees face the same puzzle sometimes.
They see risks being taken. Sometimes they take risks themselves. What is THE truth driving these behaviors

A
production quota

(as in the case of a pipe
manufacturer who recorded an injury per employee over a decade);

Timothy Ludwig’s website is Safety-Doc.com where
you can read more safety culture stories and contribute your own. Dr. Ludwig is a senior consultant with Safety
Performance Solutions (SPS: safetyperformance.com),
serves as a commissioner for Behavioral Safety Accreditation at the non-profit
Cambridge Center for Behavioral Studies (CCBS: behavior.org) and teaches behavioral psychology at
Appalachian State University, in Boone, NC.
If you want Tim to share his stories at your next safety event you can
contact him at TimLudwig@Safety-Doc.com.

The Discussion:

Tim,
what a truly philosophical blog. How nice to see you struggle as the
‘nurse’ and others with ‘what is reality’ and how do we define good,
etc. Really beautiful
and so far removed from just an R+, R- or P approach. Certainly rules
drive many kinds of bad and not so bad behavior but you did not go down
our usual path. You really did not try to solve the problem or judge the
woman’s history of reinforcement. Build
alternative ‘truths’—speaks so much to how the world and our behavior
is seen. If we then translate the ‘how to build’ we have a whole new
way to approach our clients/ the world. LOVE IT.

Darnell Lattal, Ph.D.

PRESIDENT & CEO

ADIAubrey Daniels International

**************************

Dr. Ludwig,

Like you (and huge number of others), I
was fascinated by the Brooksdale Senior Living incident. As you know it
was much bigger than a nurse locked in a Catch 22. Your personal
experience with lifeguarding was a great example.

As
usual there is no single "root cause" for this incident. Many
commenters have expressed outrage over the Nurse's decision. I would
suggest that many of them have never faced such a dilemma. As usual the
blame gets placed at the lowest level... where rubber and road actually
come together.ed

Having been a plant GM for 10+
years, I was placed in similar situations as were the 300+ employees
who worked under my direction. The tendency is always for upper part of
the "food chain" to want the hides of the lowly person or persons who
committed the dastardly crime of violating company policy or for not
having the "common sense" to violate company policy when it's suggested
that one could have done that without corporation's equivalent to
capital punishment. I have witnessed heroic actions that have saved
serious consequences and have been applauded by the CEO. Those actions
were, in fact, violations of the company safety rules. I have seen
almost identical actions where the "would-be" hero was killed! When that
happened the CEO rightly wanted an in-depth investigation to ultimately
determine who, in the line of authority, was responsible for the
numerous oversights and lack of enforcement of the rules that invariably
come out! The results usually led to discipline at the lowest level...
never on company policy makers.

Striving for
perfection in S&H is mandatory. Fixing the processes involved is
also mandatory. Too many winks occur when a risk produces a reward.
Example: Removing an obstacle in the nick of time avoided a costly
shutdown (production quota you referred to), but the method it was done
was a violation of the safety rules. Now we have a dilemma! Damned if
you do and damned if you don't. Nurse's case: Scenario one: Administer
CPR and patient dies anyway: Nurse guilty of violating company policy
and cause of lawsuit to company! Certain discharge. Scenario two:
Administer CPR and Patient lives: patient and family happy, nurse happy,
nurse supervisor reports her to bosses. Reprimand and discharge. Case
never reaches media attention. Nurse knows she did the right thing.
She's unemployed and has a blemish on her resume (defied company policy)
that may limit her working in her profession again.

You are so right. The Truth is in the eye of the beholder!

You
mention that employees should have the right to shut down the process
or equipment if he/she believes it to be an S&H issue. Wow! Talk
about a can of worms. While it sounds noble and very common sensical, I
suggest it is not always practical. There must be some fences built
before the right to shut down unsafe conditions is given to any
employee. The employee making those decisions must have knowledge about
the process. Along with a vast majority of good, knowledgeable
employees, comes a group who are not quite in that league. I've
witnessed some amazingly dumb and sometimes deliberate (union
troublemaker trying to prove a point) decisions made by employees acting
on their own that have caused many more safety incidents than would
have been caused by taking the extra time to report the incident to
someone more knowledgeable. The unintended consequences of shutting down
a piece of smoking equipment in a larger process can wreak havoc and
create great danger. Many employees are just not knowledgeable enough to
make those decisions.

As you know the key is
trust and communication. In the plant I mamaged all control operators
were given the authority to shut down a generating unit without asking
permission when they deemed a situation was too dangerous to operate. My
philosophy was that I would rather explain why we shut it down
incorrectly than why we kept it running until a disaster shut it down
for us! The trust we had in the competence and judgement of our unit
operators was solid and their belief in management standing with their
decisions was just as solid.